question

Statues or Statutory Law

answer

laws passed by legislative bodies(federal congress and state legislatures)

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Regulations

answer

guidelines written by administrative agencies

question

Case law or common law

answer

based on court decisions that establish precedent or standard

question

Civil Law

answer

deals with all areas of the law that are not classified as criminal

question

Criminal Law

answer

is public law statute or ordinance that defines crimes than their prosecution

question

Subpoena

answer

an order of the court that requires a witness to appear at a particular time and place to testify

question

Subpoena duces tecum

answer

requires documents to be produced

question

Deposition

answer

testimony under oath taken outside of court

question

interrogatory

answer

a document containing a list of questions that must be answered in writing

question

Qui tam

answer

A provision of the False Claims Act that allows a private citizen to file a lawsuit in the name of the US government, charging fraud by government contractors and other entities

question

Federal Register

answer

a legal newspaper published every business day by the National Archives and Records Administration - keeps up to date on healthcare

question

Program Transmittals

answer

contain new and changed Medicare policies and or procedures that are to be incorporated into a specific CMS program manual

question

Medicare Administrative Contractor

answer

an organization that contracts with CMS to process fee-for-service healthcare claims and perform program integrity tasks for both Medicare Part A & B

question

listserv

answer

a subscriber-based question and answer forum available through e-mail

question

Record retention

answer

the storage of documentation for an established period of time usually mandated by federal and/or state law. Purpose is to ensure the availability of records for use by government and other third parties. It is acceptable to store in a format other than the original hard copy if accurately reproduces all original documents.

question

Record Retention

answer

Mandated by state - Age of Majority - 18-need to keep 10 years after 28 7 years after inactive

question

Medicare Conditions of Participation

answer

mandate the retention of patient records in their original or legally reproduced form (e.g. microfilm) for a period of at least 5 years (MI 7 Years)

question

Heath Insurance Portability and Accountability Act

answer

Mandates the retention of health insurance claims and accounting records for a minimum of 6 years, unless state law specifies a longer period. MI-7 years

question

HIPPA

answer

mandates that health insurance claims be retained for a minimum of 2 years after a patient's death. MI-5 to 7 years

question

Health Insurance Portability and Accountability Act of 1996 - HIPPA

answer

mandates regulations that govern privacy, security, and electronic transactions standards for healthcare information. Nothing can be released without your signature.

question

What are the 5 titles HIPPA is organized according to?

answer

Health Care Access, Portability, and Renewability - Preventing Health Care Fraud and Abuse, Administrative Simplification and Medical Liability Reform - Tax Related Health Provisions - application and Enforcement of Group Health Plan Requirements - Revenue Offsets

question

Fraud

answer

an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment. Attempt whether successful or not is considered FRAUD

question

Abuse

answer

involves actions that are inconsistent with accepted, sound medical business, or fiscal practices. Directly or indirectly results in unnecessary costs to the program through improper payments.

question

What is the difference between fraud and abuse?

answer

The difference between abuse and fraud is the intent - both have the same impact in that they steal valuable resources from the health care industry.

question

What are the most common forms of Medicare fraud?

answer

Billing for services not provided-Misrepresenting the diagnosis to justify payment-soliciting, offering or receiving a kickback-Unbundling codes-faslsifying certificated or medical necessity, plans of treatment, and medical records to justify payment

question

What are examples of abuse?

answer

Excessive charges for services, equipment or supplies-submitting claims for items or services that are not medically necessary to treat the patient's stated condition-improper billing practices that result in a payment of a government program when the claim is the legal responsibility of another 3rd-party payer-Violations of participating provider agreements with insurance companies

question

If found guilty of fraud what are the consequences?

answer

Civil penalties of $5,000-10,000 per false claim plus triple damages - Criminal fines and or imprisonment - administrative sanctions

question

Overpayments

answer

Funds a provider or beneficiary receives in excess of amounts due and payable under Medicare and Medicaid statues and regulations. Once a determination of overpayment is made, the amount so determined is a debt owed to the US Government. EXP: payment based on a charge that exceeds the reasonable charge

question

Underpayments

answer

submitted claims report codes simple procedures when review of the record indicates a more complicated procedure was performed

question

Code Pairs

answer

edit pairs included in the Correct Coding Initiative cannot be reported on the same claim if each has the same date of service

question

Medically Unlikely Edits (MUEs)

answer

Implemented to improve accuracy of Medicare payments by detecting and denying unlikely Medicare claims on prepayment basis. Are used to compare units of service with code numbers as reported on submitted claims.

question

Unbundling

answer

submitting multiple CPT codes when one code should be submitted

question

Why does unbundling occur?

answer

Provider's coding staff unintentionally reports multiple codes based on misinterpreted coding guidelines. The reporting of multiple codes is intentional and is done to maximize reimbursement.

question

National Health PlanID

answer

is assigned to third-party(employer) payers; it has 10 numeric positions, including a check digit as the tenth position

question

Check Digit

answer

a one-digit character, alphabetic or numeric, used to verify the validity of a unique identifier

question

National Provider Identifier NPI

answer

is assigned to healthcare providers as a 10-digit numeric identifier, including a check digit in the last position. Goes with provider license.

question

National Standard Employer Identification Number EIN

answer

assigned to employers who as sponsors of health insurance for their employees, must be identified in healthcare transactions. It is the federal employer identification number assigned by the IRS and has nine digits with a hyphen, began 1-1998

question

Electronic Transaction Standards

answer

a uniform language for electronic data interchange. Electronic data interchange is the process of sending data from one party to another using computer linkages.

question

What must be completed prior to submitting electronic media claims to Medicare?

answer

CMS Standard EDI Enrollment Form

question

National Drug Code

answer

maintained by the Food and Drug Administration identifies prescription drugs and some OTC products

question

Privileged Communication

answer

any information communicated by a patient to a healthcare provider

question

Protected health information

answer

information that is identifiable to an individual (individual identifiers) such as names, address, telephone numbers, SSN and name of employer

question

Authorization

answer

document that provides official instruction, such as the customized document that gives covered entities permission to use specified protected health information for specified purposes or to disclose PHI to a third party specified by the individual

question

Privacy

answer

the right of individuals to keep their information from being disclosed to others. Once it is disclosed it is essential that confidentiality of the information is maintained

question

Confidentiality

answer

involves restricting patient information access to those with proper authorization and maintaining the security of patient information.

question

Security

answer

involves the safekeeping of patient information by controlling access to hard copy and computerized records; protecting pt information from alteration, destruction, tampering, or loss; providing employee training in confidentiality of pt information; and requiring employees to sign a confidentiality statement that details the consequences of not maintaining pt confidentiality

question

Breach of Confidentiality

answer

Unauthorized release of patient information to a third party

question

HIPPA Privacy Rule

answer

Provision that creates national standards to protect individuals' medical records and other personal health information

question

HIPPA Security Rule

answer

HIPPA standards and safeguards that protect health information collected, maintained, used, or transmitted electronically; covered entities affected by this rule include health plans, healthcare clearinghouses, and certain healthcare providers

question

When is it recommended that health information be faxed?

answer

When there is an urgent need for the health record, and mailing would cause an unnecessary delay in treatment. Immediate authorization for treatment is required from a primary care physician or other third-party case manager.

question

What should fax cover sheet include?

answer

Name of the facility to receive the fax Name and phone # of the person authorized to receive the transmission Name and number of the sender Number of pages being transmitted A confidentiality notice or disclaimer Instructions to authorized recipient to send verification of receipt of transmittal to the sender

question

What should a practice keep?

answer

A dated log of the transmission of all medically sensitive faxes and copies of all receipt of transmittal verifications signed and returned by authorized recipient.

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